Value-based health care: putting patients “front and centre”

PUTTING patient outcomes “front and centre” was the key to making the cultural shift from volume-based to value-based health care, say health leaders.

Dr Dan Ewald, a GP on the NSW North Coast and Lead Clinical Advisor at the North Coast Primary Health Network (NCPHN), told InSight+ that cultural change was “enormously challenging” and would take time, but the improvements in patient outcomes would be worth it.

“We all care about the patient outcomes and, if you put that front and centre, it’s a different conversation than if you are just in a hospital management hierarchy saying ‘you need to improve cost efficiency or address clinical variation’,” he said.

Clinicians across all sectors also had to recognise the importance of working not just for the patient but on improving the system, he said.

“We need the system to be flowing so it’s easy for the patient to transition in and out of specialist care and back into general practice care,” he said.

Dr Ewald was commenting on a Perspective published in the MJA, written by NSW Health leaders.

Secretary of NSW Health Elizabeth Koff and Deputy Secretary Dr Nigel Lyons said that, as with all health care systems, NSW Health was experiencing growing pressure from chronic disease, an ageing population, and the use of new technology.

“Delivering health care is increasingly complex and demanding,” they wrote. “Identifying and unlocking the value that exists in every aspect of the health system is a long term aspiration. It requires greater maturity of systems and the collective efforts of clinicians, health executives and managers.”

Value-based health care, they said, sought to deliver value across four domains: improved health outcomes, improved experiences of receiving care, improved experiences of providing care, and better effectiveness and efficiency of care.

They pointed to the Leading Better Value Care initiative as the flagship program in driving this change. The program has several initiatives, including the osteoarthritis chronic care plan, the osteoporosis re-fracture prevention program, diabetes high risk foot services, and chronic wound management programs.

Dr Ewald said a disease-centred focus had helped to engage clinicians in the change process.

“The [targeted areas] are mostly high volume conditions … where the gap between evidence-based practice and actual practice is pretty obvious,” said Dr Ewald, who has been involved in the development of several Leading Better Value Care topics in his area.

He said identifying conditions in which there could be some “fairly easy wins” had helped to bring clinicians to the table.

“Building the clinical leadership is a key, and often not well done, step [in this process],” he said.

The flipside to focusing on specific conditions, Dr Ewald said, was whole-system reform in delivering value-based, patient-centred care.

“The implementation needs to have a major emphasis on the whole health system, not just on the body part,” he said.

Dr Ewald said NSW was off to a good start in moving to value-based care, but the cultural changes required remained “enormously challenging”.

“I applaud NSW Health for doing this work,” he said. “The cultural change is always the hardest stuff. We know that you may need to chip away for many years to shift the culture.”

Dr Sidney Chandrasiri, Group Director of Academic and Medical Services at Epworth HealthCare, said designing systems to achieve optimal value for every resource used was fundamental to achieving a truly sustainable health care system.

“The issues highlighted in the [MJA] paper reflected the urgency required to achieve such a transformation. A failure to proactively plan for adequately addressing these types of emerging challenges has already led to a compounding of their consequences,” said Dr Chandrasiri, pointing to unwanted clinical variation, exorbitant out-of-pocket costs, extensive wait times, and inequitable access to health care for many Australians.

She said practical barriers to implementing value-based care included the absence of advanced, interconnected IT infrastructure and data sharing capability across both the states and nationally, which was compounded by geographical challenges.

“There needs to be a reassessment of our current funding models, an assessment of our capability for statewide clinical services planning and willingness to embrace transformation and significant change. More fundamentally, there needs to be collaboration and cohesion amongst the various health system stakeholders to shift the collective mindset from volume- to value-based health [care] models.”

The significant upfront investment – in terms of personnel and infrastructure – for long term gain presented a further hurdle, she said.

“Engaging our clinicians in viewing their clinical service delivery through a value lens will be imperative as it is likely to be quite confronting to most and will pose a particularly challenging barrier to this change.”

It’s a challenge that the NCPHN, together with the Northern NSW Local Health District, has taken on in the development of its Winter Strategy, which is about to enter its fourth year.

Under the program, about 800 patients identified as being at high risk of hospital admission during the influenza season are registered with their general practice and monitored throughout the winter months. Should a hospital admission occur, the GP is notified and is able to “reach in” to the hospital system to discuss care. Discharge notices are also promptly provided to the GP.

Both clinicians and patients involved in the program reported improved experiences. While the impact on hospital admissions has yet to be measured, the final evaluation reported that the program had a positive impact on the local culture of integrated care.

Dr Chandrasiri said a key principle of value-based health care was taking a patient-centred approach to generating value over a full cycle of care, from the hospital admission and coordinated postoperative follow-up, to ongoing disease management and preventive measures.

“Adopting a full care cycle approach to disease management, as opposed to how our current system is structured – by specialty group or by discreet interventions provided – will inevitably require primary care systems, hospital systems and outpatient/specialty care systems to align and cooperate in working together towards a common goal.”

Dr Ewald said an exciting consequence of NSW Health’s move to embrace value-based care was its potential impact on private sector care.

“I would hope to see a spillover effect of quality [health] care from the public sector into the private sector.”

He said when patients experienced evidence-based, integrated care in the public sector – such as conservative management of knee osteoarthritis before considering a knee replacement – they would come to expect that same approach in the private sector.